Provider Demographics
NPI:1316481625
Name:WIENTJES, CALVIN (CRNA)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:WIENTJES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4568 QUAIL HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5396
Mailing Address - Country:US
Mailing Address - Phone:618-638-3656
Mailing Address - Fax:
Practice Address - Street 1:4568 QUAIL HOLLOW DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-5396
Practice Address - Country:US
Practice Address - Phone:618-638-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-06
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH416443163W00000X
IL041.446613163W00000X
TN199315163W00000X
IL209.015519367500000X
KY3010948367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse